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Complex Care > Transplant > Flashcards

Transplant Flashcards

1
Q

What can be donated?

A
  1. Organs: kidney and liver are in highest demand
  2. Tissue: skin, heart valve, bone
  3. Whole body
  4. Living or cadaver
  5. Living donor cannot sacrifice life for another
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2
Q

What happens if you donated your kidney and later in life you are in need of a kidney?

A

You are bumped higher up on the list

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3
Q

If donating while living, you need..

A
  1. extensive workup
  2. meet with coordinator for patient and family education of long term issues
  3. If anonymous, need psych evaluation
  4. Insurance: pays for evaluation testing, surgery, follow-up
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4
Q

What are some challenges for the donor after donating

A

Can be emotional because you may or may not know the person that you are donating to
Person may reject the organ
The organ may not work

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5
Q

Can a person that is HIV or HepC positive donate?

A

Yes

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6
Q

How do you get on the transplant list?

A
  1. Referral and transplant center
  2. Verification of need, each organ has specific criteria
  3. Blood testing and typing
  4. List: United network for organ sharing (UNOS)
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7
Q

What will the transplant center look for when getting on the list?

A

insurance and location to transplant center

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8
Q

What is the criteria for verification of need for a kidney

A

kidney with less than 20% of function

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9
Q

Tissue typing

A
  1. Blood compatibility
  2. HLA typing
  3. Panel of reactive antibodies (PRA)
  4. Crossmatch
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10
Q

Blood compatibility

A

Must have the same ABO but doesn’t not need the same Rhfactor (+/-)

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11
Q

HLA typing

A

Three different groups of antigens
Varies by different organ
For kidneys, you need a very close match because there is a high risk for rejection

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12
Q

Panel of reactive antibodies

A
  1. Determines the patients sensitivity to HLAS
  2. Sensitivity to various HLAS recipient serum mixed with a randomly selected panel of donor lymphocytes to determine reactivity
  3. High percentage means that a person has a large number of cytotoxic antibodies and is highly sensitized. If high plasmaspheres or IVIG to lower number of preformed HLA antibodies
  4. If positive transplantation is contraindicated due to hyper acute rejection
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13
Q

Crossmatch

A

Serum from patient mixed with donor lymphocytes to test for anti-HLA antibodies to a potential organ
Negative crossmatch: has no preformed antibodies present and safe to continue the transplant

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14
Q

While waiting for a transplant patient’s must

A
  1. Be sick enough
  2. Verify labs monthly
  3. Meet criteria and constantly be evaluated (patient gets better –> moves down list, patient gets sicker –> moves up list)
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15
Q

Emotions while being on transplant list

A
  1. Guilt about self-inflicted illnesses

2. Anger that self-inflicted others are on the list

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16
Q

What is the kidney allocation system used for?

A

used to determine the score if someone is able to donate or received a kidney without having issue or rejection

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17
Q

Why was the kidney allocation system developed?

A
  1. High than necessary discard rates of kidneys
  2. Variability in access to transplants in candidates who are hard to match d/t biological reasons
  3. Inequities resulting from the way waiting time is calculate
  4. Matching system resulting in unrealized life years
  5. High retransplant rates
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18
Q

Kidney Allocation System

A
  1. Implemented in 2014
  2. waiting time starts at listing or start of dialysis, whichever comes first
  3. Donors are scored with kidney donor profile index (KDPI)
  4. Recipients scored with estimated post-transplant survival (EPTS)
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19
Q

kidney donor profile index (KDPI)

A

Age, height/weight, ethnicity, cause of death, blood pressure, diabetes, hep C, creatinine
Single number that summarized the likelihood of failure after kidney is transplanted

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20
Q

estimated post-transplant survival (EPTS)

A

Age, time on dialysis, previous solid organ transplant, current diabetes status

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21
Q

How long can heart/lungs be outside the body?

A

4-6 hours

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22
Q

How long can liver be outside the body?

A

8-12 hours

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23
Q

How long can kidney be outside the body?

A

24-36 hours

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24
Q

How long can pancreas be outside the body?

A

12-18 hours

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25
Q

what is “cold time”

A

the time that the organ spend out of the body

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26
Q

Contraindications for receiving a kidney transplant

A
  1. Disseminated malignancies or active malignancies
  2. Cirrhosis (unless on liver list)
  3. Refractory or untreated cardiac disease
  4. Chronic respiratory failure
  5. Extensive vascular disease
  6. Chronic infection
  7. Unresolved psychological disorder
  8. Obesity (BMI over 35)
27
Q

What are some psych contraindications?

A

Active alcoholism or drug use, non-adherence to medical regimens

28
Q

Things that need treatment before a transplant

A
  1. Active infection (hepatitis, DM skin or foot infections, TB)
  2. CV disease - must have angioplasty and possible CABG at least 6 months prior
  3. Ulcers healed (6 months)
  4. CVA (post 6 months)
  5. Substance abuse (resolved, 6 months of clean screens)
  6. Smoking/drinking (resolved, 6 months of sobriety)
29
Q

Live donor process

A
  1. Relative, altruistic, paired organ donation
  2. crossmatch
  3. Nephrologist
  4. 24-hour urine test
  5. Viral screening (CMV, HBV, HCV, VZV, HIV)
  6. ECG, chest x ray
  7. Renal ultrasound
  8. Transplant psychologist: emotional stability
30
Q

Why is the live donor process preferred?

A
  1. patient and graft have a higher survival rate
  2. recipients are in the best health so body is prepared for surgery
  3. immediate organ availability instead of waiting for one
31
Q

What is a reason for the live donor process tests?

A

to ensure that the donor can function without a kidney

32
Q

A decease patient can help..

A

2 patients because each patient gets one kidney

33
Q

Putting the kidney in the body

A
  1. Kidney is placed into the retroperitoneal space in the iliac fossa
  2. ureter connected to the bladder
  3. vessels connected to the iliacs
34
Q

How long can the kidney best on ice for because transplant?

A

36 hours but cold kidneys can be hard to start again and act like ATN for a couple of days to weeks

35
Q

How long is the kidney transplant surgery?

A

2 hours

36
Q

Why is it important to rapid revascularize a kidney?

A

to prevent ischemic injury to the kidney

37
Q

Transplant vs. dialysis

A

over time transplant is cheaper than dialysis and it is better for a patient with type 2 DM

38
Q

Kidney transplant life and acceptance

A

Graft life is 1-25+ years

15% rate of rejection within the first year

39
Q

Do you have to change your lifestyle after a transplant?

A

Yes

40
Q

Kidney transplant post-op: ICU

A

12-24 hours
Monitor UO: high hourly UO could be up to 1L/hr
1. Ability to filter BUN
2. fluids during operation
3. Renal tubular dysfunction so kidney cannot concentrate urine normally
4. Replace fluids 1:1 with fluid loss

41
Q

Kidney transplant post-op: monitoring

A

central venous pressure, electrolyte monitoring, K, bicarbonate

42
Q

Kidney transplant post-op: surgical complications

A

bleeding, wound infection, clotting, twisting( torsion of kidney), urine leak

43
Q

Kidney transplant post-op: Observe for ATN

A
  1. can happen with increased cold times
  2. Body can excrete fluids at this time but not metabolic wastes or electrolytes so temporary dialysis may be necessary for maintaining fluid and electrolyte balances
  3. Can last dats to weeks but remind patient that renal function will improve
44
Q

Kidney transplant post-op: Urine output catheter places for 3-5 days

A
  1. Any decrease in UO is a concern

2. Catheter may need irrigation because obstruction due to a blood vessel is a common cause of decrease UO

45
Q

Kidney transplant post-op: after discharge

A

frequent blood tests and follow up visits

46
Q

How can we help prevent or decrease rejection?

A

immunosuppressive therapy, preforming ABO and HLA matching and negative crossmatch

47
Q

Hyperacute transplant rejection

A
  1. Minutes to hours after transplant
  2. Due to preexisting antibodies against transplanted organ tissue
  3. No Treatment, removal of organ
  4. Rare, current testing prevents this from happening
48
Q

Acute transplant rejection

A
  1. Within 6 months
  2. Due to cell medicated response where recipients lymphocytes active against donated tissue, can development antibodies or humoral rejection
  3. Reversible with additional immunosuppressive therapy so increase corticosteroids or polyclonal/monoclonal antibodies
  4. put on long term immunosuppressants to prevent this
49
Q

Polyclonal antibodies

A

helps purify resultant antibody, immunosuppression and treatment for acute rejection
SE: fever, chills, increased risk of infection

50
Q

Monoclonal antibodies

A

interferes with functioning of T cells

SE: fever, chills, increased risk of infection

51
Q

Chronic transplant rejection

A
  1. months to years
  2. Due to unknown reason or repeated acute rejections
  3. B and T cells have a low grade immune mediated injury leading to fibrosis and scaring on organ
  4. Irrevesible
  5. Treatment is supportive
52
Q

Corticosteroids

A

Supresses inflammatory response

SE: PUD, HTN, osteoporosis, delayed healing, hyperglycemia, infection

53
Q

Calcineuin inhibitors

A

suppress activation of T lymphocytes by inhibiting production of cytokines, specifically IL-2
SE:nephrotoxic and HTN, NO GRAPEFRUIT JUICE

54
Q

Cytotoxic drugs

A

supressed T cells

SE: infection, leukopenia, anemia, thrombocytopenia

55
Q

Pain management post transplant

A
  1. address pain management needs
  2. Consider organ function r/t drug elimination when picking a meidcaiton
  3. pain management is essential for effective mobility q
56
Q

Complications after transplant

A
  1. Infection
  2. increased incidence of atherosclerotic vascular disease
  3. malignancies
  4. reoccurrence or original kidney disease
  5. corticosteriod-related complications
57
Q

Complications after transplant: Infection

A

significant cause of morbidity and mortality
usually within 1st month
PNA< wound infection, IV or drain infection, UTI, fungal
Fungal is due to immunodepressed and put on prophylaxis anti fungal

58
Q

Complications after transplant: increased incidence of atherosclerotic vascular disease

A

Teach patient to control risk factors

Adherence to antihypertensive are important so you don’t damage kidney

59
Q

Complications after transplant: malignancies

A

Higher rate than in the general population
Skin cancer, Hodgkins or non-hodgkins lymphoma
Due to immunosuppressive therapy

60
Q

Complications after transplant: corticosteriod-related complications

A

Hard on body so some centers may have corticosteroid free drug regimens

61
Q

Post-op care for donor surgical approach

A
  1. monitor renal function
  2. donors can have more pain than recipient
  3. discharge in 4-5 days
  4. return to work in 6-8 weeks
62
Q

Post-op care for donor laparoscopic approach

A
  1. monitor renal function
  2. pain (less that with surgical, more than recipient)
  3. discharge in 2-4 days
  4. return to work in 4-6 weeks
63
Q

Law in regard to donation

A
  1. Hospital are required by law to identify potential donors and to notify the organ procurement organization (OPO)
  2. hospital continues to manage patient
  3. OPO evaluates potential donor and approaches family about donation
  4. organs may not be sold

Complex Care (22 decks)

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